Final Report > Chapter 23: Respect and Honesty > The need for openness and honesty within the hospital > When things go wrong

When things go wrong

51 While by no means inevitable, it is likely that, despite the best efforts of the hospital's staff, there will be occasions when things go wrong. We need immediately to separate two matters: what happened and what the hospital should do about it. As regards what happened, distinctions derived from the law are commonly made between mistakes or errors on the one hand, and accidents on the other. These distinctions are concerned with the conduct of the hospital or its staff. They are not concerned with what has happened to the patient. They also ignore what we all know, that there are many factors which contribute to an event, not just the one that directly gives rise to it. In a patient-centred healthcare system, however, it is the effect on the patient which matters. Thus, we do not distinguish here between various kinds of events. We group them together as adverse events, meaning an unplanned event which results in harm to the patient. [36] We turn now to what the hospital should do in the case of an adverse event. Historically, of course, while hospitals may have been willing to disclose and discuss accidents, they have been unwilling to do so in the case of an error or a mistake because of the legal repercussions. We discuss this later in detail in Chapter 26 on Safe Care. What we say here is that even in the case of a mistake which might bring legal liability there is a duty of candour. This duty is part of and grows out of the culture of openness which we have called for. It is also a duty that is implicit in the notions of respect and honesty in dealings with patients.

52 With specific regard to an unplanned event which results in harm to the patient, the duty of candour should still apply even when mistakes are not immediately apparent and come to light later. This is so particularly when the patient may otherwise be unaware. There is already evidence that such an approach is being adopted within the NHS, for example in circumstances of misdiagnosis. We were also impressed by the policy of some US hospitals in this regard. For example, the Veterans Affairs Medical Center in Lexington, Kentucky, has a policy whereby, if it discovers an error of which the patient and family are unaware, they disclose this to the patient, even if it involves error on the part of the hospital or its staff. [37]

53 During Phase Two, we heard from Professor Lucian Leape. He said that when things go wrong, patients generally want three things: someone to tell them what has happened; a clinician to say s/he is sorry that it has occured; and action to ensure that the event will not happen to anyone else. He said that in his experience patients do not want punitive action; they want responsible action. We would add that saying sorry has nothing necessarily to do with admitting any fault. Rather it is an expression of concern for the situation in which patients find themselves. We note also the research by Linda Mulcahy and others, reported in the National Audit Office's report on clinical negligence. [38] It stated that when serious problems occur, patients may want compensation, but they also want an admission; the prevention of future incidents; an explanation; and an apology. When things go wrong, patients should not have to struggle against the system and raise formal complaints. Thus, we believe that hospitals have a responsibility to be active and to investigate adverse events. Whenever it is clear that what went wrong is the result of action or inaction on the part of the hospital or its staff, they should be under a duty to be open and honest and to acknowledge this as early as possible, ensuring that any compensation due is paid swiftly. Difficult and uncomfortable though it will be, we are convinced that this degree of openness by hospitals and healthcare professionals is essential to the maintenance of patients' trust. It is the essence of respect for and honesty towards patients. And, as we argue later, the more that is known and understood about adverse events generally, the more it will become possible to address their causes and to prevent them in the future.

54 We draw attention to the fact that compensation for harm arising from adverse events is an enormously complex subject. Currently, patients may obtain financial assistance from a variety of unrelated sources, including state and employment related benefits and, where available, legal action. Some patients receive none. The system (if such it be) needs radical re-examination. We propose later, in Chapter 26 on Safe Care, that clinical negligence litigation be abolished. We accept that there must be a review of the implications of this proposal not least as regards compensation which arises from litigation. We favour an administratively-based system of compensation based upon the needs of patients rather than on the circumstances which gave rise to those needs.

Footnotes

[36] We propose later in Chapter 26 that the term `sentinel event' be used. This term embraces adverse events and near misses and prevents disputes as to whether an event was one or the other

[37] Wu AW. `Handling hospital errors: is disclosure the best defense?', `Annals of Internal Medicine' Dec 21 1999; 131(12):970-2

[38] `Handling clinical negligence claims in England', Report by the Comptroller and Auditor General. HC403. Session 2000-2001: May 2001